Policy Design Specialist I

Responsibilities

• Implement new policies and update existing policies for clients to ensure the policy is editing in accordance with the industry and per the client’s expectation.
• Write and design client requested policies from scratch, translating client expectations into Cotiviti guidelines to ensure appropriate configuration.
• Execute projects requests, design work orders, and actively monitor queues to ensure all requests are completed by the desired completion date.
• Balance multiple priorities and manage projects deliverables for two or more healthcare clients.
• Proactively assist on other client accounts where needed.
• Provide the highest level of customer service by documenting and staying current regarding all client sensitivities and configuration needs.
• Investigate situations where configuration updates conflict with client customizations or needs.
• Meet daily and monthly production and quality targets; maintaining an exemplary level of accuracy in all work; ensuring that the capture and completion of assigned projects are audited and that corrections are made where needed.
• Perform regular quality checks to ensure accuracy for all a client’s policy set by analyzing quality reports and troubleshoot results, determining root cause(s) and promptly resolving.
• Perform Peer Review responsibilities by providing feedback to peers assisting in achieving department quality goals.
• Receive peer feedback, identifying any trends and proposing concise solutions to minimize error rate.
• Resolve testing issues and conflicts related to policy configuration updates and policy overlaps.
• Analyze pre and post client claim data to ensure appropriate claim editing.
• Participate in client presentations by providing configuration expertise and capturing client decisions.
• Coordinate and manage post-client presentation activities.

Qualifications

• Bachelor's Degree preferred or equivalent work experience.
• Coding or HIM credential preferred (RHIA, CPC, etc.).
• 1 or more years of experience / understanding of: medical terminology, anatomy and physiology.
• Health plan payment policy experience or internal company payment policy experience.
• 2 or more years of experience in claim payment/adjudication, medical payment policy, experience in hospital administration, or multispecialty experience and exposure to professional and facility claims (or equivalent Cotiviti experience).
• Proficient with Microsoft Office Suite (Word, Excel, Power Point).
• Experience with SQL preferred.
• Ability to work well in a team environment or independently and perform well under pressure.
• Strong analytical and problem-solving skills.
• Communicates with ease up and down the chain of leadership.
• Ability to handle multiple tasks, prioritize, and meet deadlines.
• Excellent verbal and written communication skills.